Erector Spinae Plane (ESP) Block: Indications and Procedure
Primary Indications
The erector spinae plane block is recommended as a first-line regional analgesia technique for video-assisted thoracoscopic surgery (VATS) and can be used for thoracic, abdominal, and hip surgeries requiring multimodal pain management. 1
Thoracic Surgery Applications
ESP block is specifically recommended for VATS as part of multimodal analgesia, showing non-inferiority to paravertebral block with comparable efficacy in reducing pain scores and opioid consumption during the first 48 hours postoperatively 1, 2
ESP block is particularly indicated when the parietal pleural leaflet is damaged, which would preclude the efficacy of a paravertebral block with catheter 1
The block provides effective analgesia with reduced pain scores and opioid consumption during the first 24 hours after VATS 2
Continuous ESP catheter placement improves Quality of Recovery-15 scores at 24 and 48 hours compared to paravertebral block 3
Cardiac Surgery
- ESP block is an acceptable alternative to thoracic epidural analgesia for cardiac surgery under cardiopulmonary bypass or off-pump procedures, with identical analgesic efficacy but fewer adverse effects 1
Breast Surgery
- For oncological breast surgery, ESP block reduces morphine consumption compared to general anesthesia alone, though PECS blocks demonstrate superior pain control after the first postoperative hour 1
Abdominal Surgery
ESP block provides both visceral and somatic analgesia for abdominal procedures including bariatric surgery, hernia repairs, and laparoscopic cholecystectomy 4, 5
The local anesthetic spreads into the paravertebral space, affecting ventral and dorsal branches of thoracic spinal nerves and sympathetic nerve fibers 4
Hip Surgery
- Lumbar ESP block (at L4 level) can serve as the main anesthetic technique for hip surgery in high-risk elderly patients when combined with mild sedation 6
Procedural Technique
Anatomical Level Selection
For VATS, perform a single injection at T4-T6 level rather than multiple injections, as multiple injections (T4-T8) have not demonstrated superior analgesia but increase procedural time and patient discomfort 2, 7
For bariatric and abdominal surgery, perform bilateral ESP blocks at T7 level to achieve visceral and somatic abdominal analgesia 5
For lumbar procedures, inject at L4 level between erector spinae muscles and transverse process 6
Ultrasound-Guided Technique
Use ultrasound guidance to identify the erector spinae muscle and transverse process at the target level 1
Inject local anesthetic into the fascial plane deep to the erector spinae muscle 5
The injectate spreads craniocaudally over several levels and penetrates anteriorly through intertransverse connective tissue into the paravertebral space 5
Dosing Recommendations
The recommended volume is 20 ml of bupivacaine 5 mg/ml (0.5%) for single-shot ESP block 2
For continuous infusion via catheter: administer 20 ml bolus of levobupivacaine 0.375% followed by infusion of levobupivacaine 0.15% at 10-15 ml/hour for 48 hours 3
For abdominal surgery: 40 ml of local anesthetic mixture (20 ml bupivacaine 0.5%, 10 ml lidocaine 2%, and 10 ml normal saline) 6
Adjuvant Considerations
Adding dexmedetomidine to ropivacaine in ESP block results in reduced pain scores, lower rescue analgesia requirements, and shorter hospital stays compared to plain ropivacaine 2
Consider adjuvants when prolonged analgesia beyond 6-8 hours is required 2
Timing
- No significant difference exists between blocks performed after incision or at the end of the procedure in terms of pain scores and opioid consumption 2
Clinical Outcomes
Efficacy Metrics
ESP block significantly reduces pain scores at rest and during coughing for the first 6-8 hours after VATS compared to placebo 2
Patients demonstrate lower opioid consumption during the first 24 hours postoperatively 2, 8
Faster postoperative out-of-bed activity occurs with ESP block 2
Meta-analysis shows ESP block reduces 24-hour postoperative opioid consumption (mean difference -17.49 mg morphine equivalents) and pain scores at rest and movement 8
Safety Profile
The incidence of hematoma is lower with ESP block compared to other regional blocks (odds ratio 0.19) 8
ESP block avoids the risks of hypotension, urinary retention, and lower limb weakness associated with thoracic epidural 1
Critical Caveats and Pitfalls
Duration Limitations
The analgesic effect of single-shot ESP block diminishes after 6-8 hours, requiring supplemental analgesia 2
- Always administer basic analgesia with NSAIDs and paracetamol concurrently with ESP block to optimize pain management 2
Comparative Effectiveness
Some studies suggest paravertebral block may provide superior analgesia compared to ESP block in the first 8 hours after surgery 2
ESP block may provide less consistent analgesia compared to paravertebral block in some patients, requiring careful assessment of individual pain control 2
For breast surgery, PECS blocks demonstrate superior outcomes after the first postoperative hour compared to ESP block 1
Anatomical Limitations
- Neither ESP nor PECS blocks reliably provide sufficient analgesia to the axilla (T1 nerve distribution), requiring supplemental local anesthetic wound infiltration for axillary procedures 1